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The HIV Epidemic in MSM in South Africa James Mcintyre The HIV Epidemic in MSM in South Africa James McIntyre MTN Regional Meeting, Cape Town, 2018 1 MSM IN SOUTH AFRICA Homosexuality in Sub Saharan Africa • Early recording of MSM activity in Africa • 2000 year-old rock paintings in a cave in Zimbabwe depict men having sex with other men Epprecht (2004) Hungochani: The History of a Dissident Sexuality in Southern Africa Homosexuality and South Africa • The first “western” reports of homosexual behaviour in South Africa date back to the days of the Dutch East India Company settlement at the Cape of Good Hope • In 1753 there was a trial of a Dutch man and two Indian slaves, who had committed mutual masturbation at the chicken house at Robben Island, off the coast of Cape Town. • The court records reflect that ‘‘not satisfied with their devilish frisky stimulation’’ they had also sodomized each other. • The consequence, following their confession, was that the three were bound together with chains and thrown overboard into Table Bay Homosexuality and South Africa • Homosexuality was variously ascribed as a foreign vice, brought in by white settlers, or by migrant workers. • Visiting the gold rush town of Johannesburg in 1912, British traveller William Scully noted the occurrence of homosexual behaviour in the predominantly male mining settlement. • In his view: it was an ‘‘undoubted fact that the Natives from some of the East Coast recruiting areas, as well as from parts of the Tropics, are addicted to those unnatural vices which, according to Holy Writ, occasioned the destruction of the “Cities of the Plain” • He also noted that : “The Shangaan Natives are the worst offenders” Homosexuality and South Africa • Sodomy" and "unnatural sexual acts" remained offences in the Roman-Dutch common law of South Africa. • These offences criminalised acts such as anal sex, oral sex, intercrural sex and mutual masturbation between men, but did not apply to, In 1987, a conviction for example, men merely touching or kissing each under the section was reversed on appeal other. because the court ruled that "a party" was not • The apartheid era brought new controls and legal created when a police restrictions, with the ruling National Party viewing officer entered a room in a gay bathhouse homosexuality as a ‘‘threat to white civilization’’ because the two men in the room jumped apart • In 1969 Clause 20A was added to the Immorality when he switched on Act, known as the ‘‘three men at a party clause’’. the light. Homosexuality and South Africa • South Africa’s post- apartheid constitution outlaws discrimination based on sexual orientation • Same Sex Marriage is legal 7 Public Attitudes are Complex Progressive Prudes. 8 The Other Foundation. 2016 “Traditional” culture, queer identity, and HIV ‘South Africa remains a homophobic, heterosexist society where, across cultures, homosexuality is pathologised, and where cultural discourses such as the notion that “homosexuality is not African” continue to play themselves out.’ Henderson and Shefer 2008 South Africa MSM: Varying Population Size Estimates Number Source Population 750,000 Extrapolation from “Ever had sex with a man” a to two research studies 1,200,000 564,979 UNAIDS Not stated b 870,000 Facebook derived Men >18 with “same sex interest” c estimates 430,000 Facebook derived Men >18 “interested in men and c estimates women” 299,013 UCSF/SANAC Men 16 – 49, reporting sex with a d man in last six months a] NDOH & SANAC 2017; b] UNAIDS 2016; c] Baral; et al JMIR Public Health Surveill 2018; d] UCSF & SANAC 2018 10 MSM Population Size estimates Based on the IBBS surveys done by UCSF & Anova 2015 - 2017: National population size estimate - 299 013 1.7% of national male population 16 – 49 according to 2015 census data • Largest metropolitan areas: 2.2% of males • Towns & Cities <1 million population: 1.4% of males • Estimates based on RDS data which included only men who reported sex with another man “recently” (within six months) • Caution on extrapolating from the five city IBBS data to a national figure • Represents “median plausible estimate” – likely to be conservative UCSF/SANAC 2018 11 2 HIV IN MSM IN SOUTH AFRICA 12 AIDS in South Africa First South African publication: 1983: • two cases in homosexual men, • both died in 1982 AIDS in South Africa September 1986: “The present status of AIDS cases in the RSA is: (i) South African residents – 30 cases comprised of: • homosexual/bisexual men (26), • heterosexual (I), • blood transfusion AIDS (I), and haemophiliacs (2); all these are white males;” R Sher, SAMJ, 1986 HIV among MSM in South Africa (2005 – 2013) HIV prevalence Investigator(s) Location Sample size 12% (2-30%) Jewkes et al (2006) Rural Eastern Cape 47 13% (12 – 14%) Lane et al (2008) Soweto 378 44% (38 – 50%) Rispel et al (2008) Jhb, Durban 266 14% Sandford et al (2008) Cape Town, Jhb, DBN 692 10% Burrel et al (2009) Cape Town (urban) 542 26% Baral et al (2010) Cape Town (peri-urban) 200 20% - 50% Jewkes et al (2010) Eastern Cape & KZN 1 738 36% Tucker et al (2012) Cape Town 171 37% Lane et al (2013) Mpumalanga 144 HIV incidence Investigator(s) Location Sample size 7% Grant et al. (2010) Cape Town, global 88 10% SACEMA (2009) Modelled on published data Published data Adapted from Mbengashe, 2012 WHO-AFRO Regional Meeting on Key Populations HIV among MSM in South Africa (2013 – 2017) Recent IBBS work in six cities across South Africa shows varying prevalence and risk groups Cape Town Johannesburg Durban 22.3% 26.8% 48.2% HSRC Marang Study HSRC Marang Study HSRC Marang Study 2013/2014 2013/2014 2013/2014 22.5% 33.6% UCSF/Anova UCSF/Anova 2015/2016 2015/2016 Polokwane: 19.2% Bloemfontein: 16.8% 37.5% Mafikeng: 16.6% TRANSFORM Port Elizabeth: 13.8% 2017 UCSF/Anova 2015/2016 16 MSM HIV prevalence and incidence estimates National HIV prevalence estimate in MSM: 31% Prevalence rates vary widely across cities in the IBBS data: UCSF/SANAC 2018 HIV Incidence in MSM: Few data but very high incidence rates reported: 9.5 – 12.5/100PY (Kamali 2014, Lane 2016) 17 High incidence in MSM • The Mpumalanga Men’s Study : 3 serial cross-sectional surveys of MSM recruited through respondent-driven sampling between 2012 and 2015. Successive surveys recaptured a nested cohort of 179, contributing 144.3 person-years (PY) of observation. • We observed 18 seroconversions, or incidence of 12.5/100 (PY) (95% confidence interval CI: 8.1 to 19.2/100 PY). • High incidence among MSM demonstrates an urgent need for biomedical prevention and treatment programming for MSM in South Africa. (J Acquir Immune Defic Syndr 2016;73:609–611) Drivers of the MSM epidemic • Relative lack of research data among South African MSM on: • Acceptability of new biomedical approaches • Behavioural factors • Factors affecting unprotected anal intercourse • Mental health factors • Recreational drug use • Stigma and discrimination • Mainstream health services experiences • ART adherence and retention in care • Condom and lubricant use 5 3 MSM CLINICAL SERVICE NEEDS Healthcare, homophobia and HIV • The experience of discrimination based on sexual orientation at clinics and health facilities acts an important deterrent to seeking medical care and going for HIV tests. • Gay-identified men sought out clinics with reputations for employing staff who respected their privacy and their sexuality • Non-gay-identified MSM presented masculine, heterosexual identities when presenting for sexual health problems and avoided discussing their sexuality with healthworkers (Lane, 2008) 90-90-90 MSM cascade Estimated Aware of their On HIV Virally MSM living +ve HIV status treatment suppressed with HIV (100%) 41% 28.1% 26,5% 92,462 37,916 26,006 24,502 Case finding Linkage to Once started on remains treatment is 67% - treatment, most very important needs to improve MSM (94%) remain in care PEPFAR22 South Africa COP18 SDS Health4Men’s Public sector programme Building “MSM competent” clinical services • “Centre of Excellence” clinics: • Cape Town, Johannesburg • Regional Leadership sites in 9 provinces • Trained “competent” sites in 9 provinces MSM Clinic Competency training: 420 facilities | 17 500 Staff trained on sexual diversity 6 500 staff trained in MSM clinical care |1 525 Staff trained in TG clinical care Changing attitudes and building skills at public clinics • Recent TRANSFORM Study in Johannesburg assessed satisfaction with HIV Care for HIV positive MSM and TG • 75.6% attended HIV care at public clinics and 18.1% MSM-specific clinics. • 89.3% were satisfied with their last clinic’s privacy, and TRANSFORM Study, Johannesburg • 91.5% with the respect they were AIDS 2018 shown. 24 Health4Men’s Private Sector Programme • Private Sector practitioner training programme: supporting “MSM competent” clinical services • Yellow Dot Doctor Academic Detailing Extending clinical competence in MSM services The Health4Men model forms the basis of Anova’s technical assistance and training in other regional countries • Collaborative work: • EQUIP • LINKAGES • International HIV AIDS Alliance • MSF • Health4Men has now worked in Angola, Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Uganda, Zimbabwe, Haiti 5 4 MSM HIV PREVENTION NEEDS MSM Community Reach Required Interventions Treatment initiation Alternative ART distribution strategies Adherence HIV Virtual STI treatment / Condoms & lubricant Positive community reach 20% highest risk -ve MSM – identify and offer PrEP Physical community Reach, educate reach Test, re-test, self test HIV Negative Assess risk & treat STI Condoms & lubricant Private practice users Educate, HIV testing
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